Complications of obliterative versus reconstructive vaginal surgery for pelvic organ prolapse in octogenarians: A retrospective cohort study.

AIMS: Women of advanced age may choose between restorative or obliterative surgery for surgical management of pelvic organ prolapse. Obliterative surgery is traditionally reserved for a subset of older women with more severe medical comorbidities, since obliterative approaches are generally considered to be less morbid and older individuals have higher rates of perioperative complications than younger cohorts. This study compared perioperative complications amongst octogenarians undergoing obliterative versus reconstructive approaches. This data will help to inform perioperative counselling as previous studies have not been powered to evaluate complications in this population. METHODS: The National Surgical Quality Improvement Program database was used to identify patients that had Pelvic organ prolapse surgery between 2012 and 2021, aged 80 years or older. Single-compartment procedures, vaginal mesh procedures, and oncologic surgery were excluded. The primary outcome was any complication within the first 30 days excluding urinary tract infection (UTI). UTI, readmission, and severe complications were secondary outcomes. RESULTS: Of the 4149 patients identified, 2514 (60.6%) underwent reconstructive surgery and 1635 (39.4%) underwent obliterative surgery. Patients undergoing reconstructive surgery were more likely to have an American Society of Anesthesiologists (ASA) class of 1 or 2 (46.1% vs. 31.3%, p = 0.002) and were less likely to be on antihypertensive medication (72.0% vs. 75.8%, p = 0.006). Further, there was an increased length of stay (1.47 ± 1.84 vs. 1.03 ± 1.31 days, p < 0.001) in hospital for reconstructive surgery which was more often performed as an inpatient (45.7% vs. 37.9%, p < 0.001). There was no difference in the primary outcome: any complication excluding UTIs. However, UTI was more common in the reconstructive group (aOR 0.48; 95% confidence interval 0.34-0.0). The rate of serious complications (Clavien-Dindo Class IV) was low overall and not different between reconstructive and obliterative approaches (1.3% vs. 1.0%, respectively). CONCLUSIONS: Both vaginal reconstructive and obliterative approaches have low complication rates in octogenarians, with only UTI rate being different between cohorts. When choosing surgical approach, we suggest a case-based, patient center discussion on the anatomic outcomes, durability and patient satisfaction.

Effectiveness of prophylactic pharmacological hemostatic agents for reduction of blood loss at vaginal surgery: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the effectiveness of pharmacological hemostatic agents in the reduction of blood loss at vaginal surgery. METHODS: A systematic review of randomized control trials (RCTs) was completed. We searched PubMed (1946-2022), Embase, and CINAHL, using search terms related to vaginal hysterectomies and reconstructive surgeries combined with peri-operative use of hemostatic agents. RCTs comparing hemostatic interventions with placebo or with standard care were analyzed with the primary outcome of estimated blood loss. Secondary outcomes included peri-operative complications, length of stay, blood transfusion, and readmission. Risk of bias was assessed using the Risk of Bias 2 tool. RESULTS: Nine RCTs were included with a total of 903 participants. All trials were considered to have an overall low risk of bias. Meta-analysis of six RCTs (491 participants) favored the use of vasoconstrictive agent (vasopressin/ornipressin) at the surgical site for an overall effect estimate of decreased blood loss by 70 ml (95% CI -125, -14 ml). There was significant heterogeneity of studies with both dose and technique of vasoconstrictive agents used. Only one RCT evaluated tranexamic acid and found a benefit in the prophylactic use of intravenous tranexamic acid. CONCLUSIONS: Peri-operative use of vasoconstrictive agents slightly reduces bleeding in women undergoing elective vaginal surgery. Additional studies evaluating alternative pharmacological agents such as tranexamic acid may be of benefit.

Prevalence and risk factors for urinary incontinence up to 2 years postpartum: a cross-sectional population-based study.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is common in the postpartum period; however, most studies focus on the early postpartum period and assess prevalence at only one or two time points. We hypothesized that UI would be prevalent across the first 2 years postpartum. Our secondary objective was to evaluate risk factors for postpartum UI among a nationally representative, contemporary sample. METHODS: This cross-sectional, population-based study used National Health and Nutrition Examination Survey (2011-2018) data for parous women within 24 months following delivery. Prevalence of UI, UI subtypes, and severity were estimated. Multivariate logistic regression was used to estimate adjusted odds (aOR) of UI for exposures of interest. RESULTS: Among 560 postpartum women, prevalence of any UI was 43.5%. Stress UI was most common (28.7%), and most women (82.8%) experienced mild symptoms. There was no significant change in prevalence of UI across the 24 months following delivery (R2 = 0.004). Individuals with postpartum UI tended to be older (30.3 ± 0.5 versus 28.8 ± 0.5 years) and had higher BMI (31.1 ± 0.6 versus 28.9 ± 0.6). In multivariate analysis, odds of postpartum UI were higher for women who had had a prior vaginal delivery (aOR 2.0, 95% CI: 1.3-3.3), prior delivery of a baby weighing 9 lb (4 kg) or more (aOR 2.5, 95% CI: 1.3-4.8), or who reported current smoking (aOR 1.5, 95% CI: 1.0-2.3). CONCLUSIONS: During the first 2 years postpartum 43.5% of women report UI, with relatively stable prevalence over this period. This high prevalence supports screening for UI after delivery regardless of risk factors.

Women's attitudes towards pessary self-care: a qualitative study.

INTRODUCTION AND HYPOTHESIS: Patients with vaginal pessaries can learn to care for their pessary by themselves or they can have provider-led care, which requires more frequent follow-up visits. We aimed to understand motivations for and barriers to learning self-care of a pessary to inform strategies to promote pessary self-care. METHODS: In this qualitative study, we recruited patients recently fitted with a pessary for stress incontinence or pelvic organ prolapse, and providers who perform pessary fittings. Semi-structured, one-on-one interviews were completed to data saturation. A constructivist approach to thematic analysis using the constant comparison method was used to analyze interviews. A coding frame was created following independent review of a subset of interviews by three members of the research team and this frame was used to code interviews and develop themes through interpretive engagement with the data. RESULTS: Ten pessary users and four health care providers (physicians and nurses) participated. Three major themes were identified: motivators, benefits, and barriers. There were several motivators for learning self-care, including care provider advice, personal hygiene, and ease of care. Benefits of learning self-care included autonomy, convenience, facilitation of sexual relations, avoidance of complications, and decreased burden on the health care system. Barriers to self-care included physical, structural, mental, and emotional barriers; lack of knowledge; lack of time; and social taboo. CONCLUSIONS: Promotion of pessary self-care should focus on patient education about benefits and ways of mitigating common barriers while focusing on normalizing patient engagement in pessary self-care.

Prevalence and Risk Factors for Urinary Incontinence in Nulliparous Women: A Contemporary, Population-Based Cohort Study.

IMPORTANCE AND OBJECTIVES: Epidemiologic studies of incontinence largely focus on parous women, and there are limited data regarding nulliparous women. Our objectives were to evaluate risk factors for urinary incontinence among a nationally representative, contemporary sample of nulliparous women of all ages in the United States and to describe the prevalence and subtypes of urinary incontinence and nocturia in this population. STUDY DESIGN: This cross-sectional, population-based study used the National Health and Nutrition Examination Survey cycles 2011-2018 to assemble a sample of nulliparous women 20-80 years old. Crude and adjusted odds ratios were estimated using multivariable logistic regression for the exposures of interest: body mass index (BMI), age, physical activity, prior hysterectomy, and current smoking. Prevalence of urinary incontinence and nocturia were estimated. RESULTS: Among 1,603 nulliparous women, prevalence of any urinary incontinence was 29.38%. Prevalence of stress, urgency, and mixed urinary incontinence and nocturia, respectively, were 27.68%, 19.64%, 10.57%, and 58.95%. Women with a BMI ≥25 (calculated as weight in kilograms divided by height in meters squared; adjusted odds ratio [aOR], 1.57; 95% confidence interval [CI], 1.11-2.23), at least 45 years (aOR, 3.75; 95% CI, 2.31-5.83), and current smoking (aOR, 1.63; 95% CI, 1.07-2.49) had increased the odds of incontinence compared with women without these risk factors. When stress urinary incontinence (SUI) was considered alone, only women with a BMI ≥25 (aOR, 1.66; 95% CI, 1.20-2.31) and age at least 45 years (aOR, 3.17; 95% CI, 2.01-5.00) had increased odds of SUI compared with women without these risk factors. CONCLUSIONS: Urinary incontinence and nocturia are prevalent in nulliparous women, and age, elevated BMI, and current smoking may represent risk factors for incontinence in this population.

Technical Update No. 433: eHealth Solutions for Urinary Incontinence Among Women.

OBJECTIVE: The purpose of this technical update is to establish the state of the science regarding emerging and novel electronic health (eHealth) and mobile health (mHealth) solutions for urinary incontinence among women. TARGET POPULATION: Women over 18 years with urinary incontinence. OPTIONS: Websites and mobile health applications are useful in the conservative care of urinary incontinence. Relevant care providers should be familiar with such tools, particularly those that use motivational principles for behaviour change, which can be used as adjunct tools for urinary incontinence care. Telemedicine is an effect mode to provide services for the conservative care of urinary incontinence. OUTCOMES: Use of eHealth and mHealth solutions has potentially significant health outcomes for patients, providers, and global health systems. Broader use of telemedicine, in and of itself, could improve care access and reduce costs incurred by patients and the health care system. BENEFITS, HARMS, AND COSTS: Evidence for the efficacy of eHealth and mHealth technologies and applications for urinary incontinence ranges from weak to strong. However, the research landscape for many of these novel solutions is developing rapidly. Furthermore, these options have minimal or no harm and confer an established cost benefit and care access benefit. EVIDENCE: The Cochrane Library, Medline, EMBASE, CENTRAL databases (from January 2014 to April 2019) were searched to find articles related to conservative care of urinary incontinence in women (over 18 years) and studies on eHealth and mHealth interventions for urinary incontinence. Articles were appraised, and the collective evidence was graded. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Relevant primary care providers and medical specialists, including physicians, nurses, midwives, and pelvic health physiotherapists. SUMMARY STATEMENTS: RECOMMENDATIONS.

The use of tissue adhesive in management of genitourinary fistulas: a systematic review and case report.

INTRODUCTION AND HYPOTHESIS: Articles are getting published on the use of tissue adhesive for vesicovaginal fistula. The objective is to carry out a systematic review on their effectiveness and complications. METHODS: A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Two reviewers screened abstracts and full-text and extracted data independently. A narrative synthesis was conducted given the heterogeneity of studies. RESULTS: A total of 1032 studies were identified after searching the database, and 14 articles were included in this systematic review. Of the 84 women included, 12 (14.3%) presented failure or recurrence of their fistula tract. The mean time of follow-up was 11.46 months. The average size of the fistula was 1.05 (range 0.1 to 3.9) cm. Most fistulas (81) included were vesicovaginal fistulas. Nine papers reported the usage of fibrin glue in which only three (6.5%) women reported recurrence of the fistula in a delay of 2 weeks to 26 months. The other studies used cyanoacrylate (14 women) and autologous fibrin injection from the patients' blood (31 women). No significant complications were reported. Complications reported were urinary tract infections in 3 women (3.6%), hematuria in 2 women (2.4%), overactive bladder symptoms in 6 women (7.2%) and septic pelvic thrombosis in one woman (1.2%). CONCLUSIONS: Tissue adhesive appears to be a promising alternative for management of urogenital fistulas without reported important complications.

Complications Following Posterior Colporrhaphy With and Without Anal Sphincteroplasty: An Analysis of Cases in the National Surgical Quality Improvement Program Database.

OBJECTIVE: We aimed to compare postoperative complications for patients undergoing posterior colporrhaphy with or without sphincteroplasty. METHODS: A retrospective cohort of women undergoing posterior colporrhaphy with or without anal sphincteroplasty was completed using the National Surgery Quality Improvement Program (NSQIP) database (2012-2019). The primary outcome was a composite of important surgical complications, including wound complications, blood transfusion, hospital stay >48 hours, reoperation, readmission, and urinary tract infection. Multivariable logistic regression was used to adjust for important potential confounders, including age, BMI, diabetes, and anterior prolapse surgery. RESULTS: A total of 5079 patients were included. Of these, 82 patients underwent a concurrent sphincteroplasty. The primary composite outcome occurred in 10.4% of patients having posterior colporrhaphy versus 19.5% having posterior colporrhaphy with sphincteroplasty. On multivariable analysis there was no increased odds of complication associated with concomitant anal sphincteroplasty (1.58, 95% CI 0.89-2.90, P = 0.12). CONCLUSION: Nearly one in five women who have posterior colporrhaphy with anal sphincteroplasty had an important surgical complication. Higher complication rates may be related to patient factors, as this was not observed after adjustment for patient factors and additional surgical procedures. Sphincteroplasty may be considered with posterior colporrhaphy in select women.

Complications After Uterosacral Ligament Suspension Versus Sacrospinous Ligament Fixation at Vaginal Hysterectomy: A Retrospective Cohort Study of the National Surgical Quality Improvement Program Database.

IMPORTANCE: Apical suspension, including uterosacral ligament suspension (USLS) and sacrospinous ligament fixation (SSLF), is the standard of care at vaginal hysterectomy. Although the equivalence of anatomic and clinical outcomes after USLS and SSLF is established, comparing surgical complications specific to patients undergoing concurrent vaginal hysterectomy further informs decision making regarding operative approach. OBJECTIVE: This study aims to compare complications in the first 30 days after surgery in patients undergoing USLS and SSLF at vaginal hysterectomy for pelvic organ prolapse. STUDY DESIGN: This retrospective, population-based cohort study used the American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing USLS or SSLF at vaginal hysterectomy for pelvic organ prolapse between 2012 and 2019. The primary outcome was a composite of surgical complications excluding urinary tract infection (UTI). Odds of the primary outcome, readmission, reoperation, and UTI were evaluated by multivariable logistic regression models. RESULTS: Of 10,210 eligible patients, 7,127 patients underwent USLS and 3,083 patients underwent SSLF. Uterosacral ligament suspension was associated with a 25% lower odds of the composite complication outcome that excluded UTI compared with SSLF (adjusted odds ratio, 0.75; 95% confidence interval, 0.63-0.90). Urinary tract infection was the most common complication and occurred more commonly in patients undergoing USLS (6.5% vs 4.9%; adjusted odds ratio, 1.29; 95% confidence interval, 1.06-1.56). There was no significant difference in Clavien-Dindo class IV complications, readmission, or reoperation between approaches. CONCLUSION: Uterosacral ligament suspension was associated with a lower odds of complications excluding UTI compared with SSLF. Urinary tract infection was more common among patients having USLS. The odds of serious complications, readmission, and reoperation were low and comparable between groups.

Technical update nº 433: eHealth solutions for urinary incontinence among women

The purpose of this technical update is to establish the state of the science regarding emerging and novel electronic health (eHealth) and mobile health (mHealth) solutions for urinary incontinence among women. Target population Women over 18 years with urinary incontinence. Websites and mobile health applications are useful in the conservative care of urinary incontinence. Relevant care providers should be familiar with such tools, particularly those that use motivational principles for behaviour change, which can be used as adjunct tools for urinary incontinence care. Telemedicine is an effect mode to provide services for the conservative care of urinary incontinence. Use of eHealth and mHealth solutions has potentially significant health outcomes for patients, providers, and global health systems. Broader use of telemedicine, in and of itself, could improve care access and reduce costs incurred by patients and the health care system. Evidence for the efficacy of eHealth and mHealth technologies and applications for urinary incontinence ranges from weak to strong. However, the research landscape for many of these novel solutions is developing rapidly. Furthermore, these options have minimal or no harm and confer an established cost benefit and care access benefit. The Cochrane Library, Medline, EMBASE, CENTRAL databases (from January 2014 to April 2019) were searched to find articles related to conservative care of urinary incontinence in women (over 18 years) and studies on eHealth and mHealth interventions for urinary incontinence. Articles were appraised, and the collective evidence was graded. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). Relevant primary care providers and medical specialists, including physicians, nurses, midwives, and pelvic health physiotherapists.

Association between obstetrical anal sphincter injury and postpartum urinary retention: a contemporary nationwide cohort study.

INTRODUCTION AND HYPOTHESIS: Identification and prompt management of postpartum urinary retention after vaginal birth is essential to minimize long-term morbidity. Obstetrical anal sphincter injuries (OASIS) have been identified as a possible risk factor for urinary retention. The objective of this study was to estimate the association between OASIS and postpartum urinary retention and compare the length of hospital stay and cost of admission between postpartum patients who experienced urinary retention and those who did not. METHODS: We conducted a population-based, retrospective cohort study of pregnant individuals delivering singleton fetuses via vaginal birth in the United States using the National Inpatient Sample (NIS) database. Multivariate logistic regression models were used to estimate the odds ratio (OR) for the association between OASIS and postpartum urinary retention. Simple linear regression was used to compare means. RESULTS: A total of 2,013,052 delivery admissions were included, which was representative of a population size of 10,065,253 utilizing the complex sampling design of the NIS database. 47,192 (2.34%) admissions sustained OASIS and 5,339 (0.27%) admissions experienced overt urinary retention. After adjusting for potential confounders, vaginal deliveries where OASIS occurred had 3.60 times the odds of postpartum urinary retention compared with vaginal deliveries where OASIS was not sustained (95% CI 3.26-3.97). Postpartum urinary retention was associated with an increased mean length of stay (2.94 vs 2.28 days, p<0.001) and 1.37 times the mean total cost of admission (US$22,946.38 vs US$16,758.85, p<0.001). CONCLUSIONS: Obstetrical anal sphincter injuries are associated with increased odds of postpartum urinary retention compared with vaginal deliveries where OASIS did not occur.

Complications After Vaginal Vault Suspension Versus Minimally Invasive Sacrocolpopexy in Women With Elevated Body Mass Index: A Retrospective Cohort Study Using Data From the National Surgical Quality Improvement Program Database.

IMPORTANCE: Overweight and obese women represent a growing share of pelvic floor reconstruction surgeons' practices. Determining perioperative risk specific to this population is essential to inform decision making regarding operative approach in this population. OBJECTIVE: The aim of the study was to compare surgical complications among overweight and obese women undergoing apical compartment prolapse surgery by either minimally invasive abdominal or vaginal approach. STUDY DESIGN: The American College of Surgeons National Surgical Quality Improvement Database was used to identify overweight and obese patients (body mass index ≥ 25) undergoing either minimally invasive sacrocolpopexy (MISC) or vaginal vault suspension (VVS) in the form of a sacrospinous vault fixation or uterosacral ligament fixation for pelvic organ prolapse from 2012 to 2019. Odds ratios for surgical complications, readmission, and reoperation were estimated using multivariable logistic regression. RESULTS: Of 8,990 eligible patients, 5,851 underwent a VVS and 3,139 patients underwent MISC. There was a greater odds of any complication in the first 30 days following VVS (n = 608 [10.4%]) compared with MISC (n = 247 [7.9%]; odds ratio, 1.27; 95% confidence interval, 1.08-1.48) on multivariable analysis. Urinary tract infections (UTIs) were the most common complication and were more likely following VVS (112 (3.6%) versus 350 (6.0%), P < 0.001). When UTIs were excluded, there was no difference in complications between approaches (1.00; 95% CI, 0.82-1.22). There were no statistically significant odds of readmission, reoperation, or serious complications between approaches. CONCLUSIONS: Vaginal vault suspension may be associated with a higher odds of any complication compared with MISC in overweight and obese women, but the rate of serious complications, readmission, and reoperation are low, and approaches were comparable when considering complications other than UTI.

Short term complications in mesh augmented vaginal repair of pelvic organ prolapse are not higher when compared with native tissue repair.

INTRODUCTION AND HYPOTHESIS: Accumulating evidence regarding the negative long-term consequences of transvaginal mesh-based procedures for pelvic organ prolapse has led to a sharp decline in mesh-based procedures. We aimed to evaluate the short-term complications of mesh-based procedures for carefully selected patients with pelvic organ prolapse after Food and Drug Administration warnings. METHODS: A retrospective database review of the ACS NSQIP database was completed to examine 30-day complications including re-operation, prolonged length of stay, blood transfusion, surgical site infection, urinary tract infection, readmission and wound dehiscence in mesh-augmented and native tissue-based transvaginal procedures for pelvic organ prolapse. RESULTS: A total of 36,234 patients were included in the analysis, with only 7.1% (2574 women) having mesh-augmented repair. Using a multivariable logistical regression analysis adjusting for confounders, we found that the primary composite outcome (re-operation, hospital stay, blood transfusion and surgical site infection) was less common in the mesh group compared with the native tissue repair group (adjusted OR 0.80, CI 0.67-0.95, p = 0.009). The secondary outcomes (urinary tract infection, re-admission and wound dehiscence) were not different between the group. CONCLUSION: These results suggest that in well-chosen patients, short-term complications are not increased when using transvaginal mesh for pelvic organ prolapse repair.